Initial Survey

There are many criteria that are used in determining qualified surrogates.  Our first step towards determining whether you qualify to be a surrogate is the Initial Survey.  To see if you qualify to become a surrogate, please fill out all the fields below. A member of our staff will get in touch with you.

Name:

 

Date of Birth:

 

Ethnicity:

 

Address:

 

Email:

     

Home Phone:

 

Work Phone:

Cell:

Height:

in  

Weight:

in  

Body Mass Index:

    

Tobacco use:

YesNo  Comments:  

Alcohol use:

YesNo  Comments:  

Drug use:

YesNo  Comments:  

Tatoos/Piercings within 1 year:

YesNo  Comments:  

Medical Illness:

YesNo  Comments:  

Previous Surgery:

YesNo  Comments:  

Marital Satus:

YesNo  Comments:  

Monogamous:

YesNo  Comments:  

Currently in Relationship:

YesNo   

Have both ovaries:

YesNo   

Have monthly periods:

YesNo   

Previous pregnancies:

YesNo   

Medications currently on:

 

Date of last period:

 

Current form of birth control:

 

Are you willing to self-administer daily injections for up to 5 weeks?

YesNo  

Are you aware you will have to stop using hormonal birth control?

YesNo     

Flexibility in work hours?

YesNo  

Would you be able to come to the office for frequent/daily monitoring?

YesNo  


Why do you want to be a surrogate?    

How did you hear of our program?